Concerned about post-op PSA

Some background information:

60 yo, otherwise healthy, diagnosed March 2017 with PCa following PSA of 5.67 and biopsy showing 3 of 12 positive samples. 3+4=7 Gleason. Radical prostatectomy July 2017 with pathology showing adenocarcinoma, one focus, 4(90%)+3=7. Extraprostatic extension in the right apical and right mid. Positive margins to the right apical, multifocal, and posterolateral, focal. Negative bladder neck invasion, negative seminal vesicles, negative lymph nodes. Final results pT2c N0 MX R1.

I was concerned about the positive margins, but first post-op PSA came at 0.01, which was reassuring. 3 months later, I had the repeat PSA done at my home lab, which came to 0.1, clearly more concerning, but was not a USPSA test. I called to have the test repeated at the original lab at the same time as my appointment. The results weren't in, but the doctor said there must have been a lab error and that PSA simply doesn't behave in that way. If it was going up, it would have gone to 0.02 or similar.

Needless to say, I got the results back after leaving the office and it came back at 0.09. This seems to me to be a huge leap. The doctor suggests waiting 3 months and repeating the test. How comfortable can I be waiting that period of time? I understand the need to see a trend, but it seems that it may be moving dramatically, despite being called lower risk.

Welcome to HW.

I am with TA on this - not the numbers you wanted. A referral to an RO is the next step.

Andrew

There are some lingering issues with continence, but it has mostly resolved.

I was hoping there was a possibility this was just retained benign tissue. The study you presented seems to indicate that is extremely unlikely.

That is true that it is extremely unlikely that retained benign tissue is responsible. The PSA from benign tissue disappears fairly quickly and would be negligible by now.

Researchers looked at a very large sample of post-prostatectomy men who had very low risk PC at the time of prostatectomy. They reasoned that in such men, any tissue left behind was very likely to be benign. There is almost always some benign tissue left behind, especially at the anastomosis where prostate tissue is scraped away from the urethra, and at the apex, where the capsule is indistinct. They measured their PSA on an ultrasensitive PSA test starting 3 months post surgery. They found that only 6 in a thousand had any measurable PSA. They conclude:

"A measurable PSA level or biochemical recurrence was an extraordinarily rare event in our select group of patients with extremely low-risk disease. These results provide compelling evidence that retained benign prostatic elements are an unlikely source of elevated PSA levels in men who have undergone radical prostatectomy."

www.goldjournal.net/article/S0090-4295(08)01520-3/fulltext

Now, in some men, the retained tissue, although it isn't completely benign, may be Gleason 6 of the sort that only progresses to more aggressive disease about half the time. In such men, a genomic classifier (Decipher) may help them decide whether they can live with that PC inside, or whether it is likely to metastasize. But in your case, you have a large proportion of Gleason pattern 4, which always carries a high metastatic potential. Your detectable and rapidly rising PSA coupled with your adverse pathology are obvious risk factors, so I don't think there is really any question.

On the upside, your positive margins auger well that salvage RT will be curable if you do it soon enough. That's because it raises the likelihood that your PSA is from retained malignant tissue rather than from micrometastases, and that can be zapped to kingdom come.

Wow, not exactly what you would like to have as numbers. You need to be with a very good RO that specializes in PC. The escalation of your psa is troubling, especially with your path report. ART is the standard care for your situation. As stated above, there are links to studies which show treatment as early as .03 produce better results in cure. If you don't care about cure (LOL), then just sit back and wait to see if the number continues escalating at this pace. I had SRT 30 months ago. No real problems- current reading is <.006. My psa at initiation of SRT was .06. You are already past that mark. You still have a chance at beating the beast!

Thank you all for all the well-researched responses.

I addressed this with the surgeon today, and he downplayed my concerns. His feedback was that 0.09 is very low and he would not recommend starting radiation until PSA stays .2 or above for 2 consecutive readings.

I am torn as I had nerve sparing surgery and don't want to overreact.

I am being seen at a facility ranked in the top 5 for prostate cancer care. Is there controversy over optimal levels for starting radiation? I'm confused why they would be operating off of outdated research, if that's what's happening.

Hi Fairwind,

What did you mean by this:

Do you have any incontinence issues ? Try to get that rectified before you start any SRT...

Thanks,

Nick

InTheShop wrote ".2 is an older standard of care". But all the guidelines i know of; European Association of Urology (EAU); American Urological Association (AUA); American Society for Radiation Oncology (ASTRO) etc use the 0.2 definition of BCR.
E.g. AUA guideline
"Clinicians should define biochemical recurrence as a detectable or rising PSA value after surgery that is ≥ 0.2 ng/ml with a second confirmatory level ≥ 0.2 ng/ml. (Recommendation; Evidence Strength: Grade C)".

Does anyone know of any PC guideline that use a another definition for BCR?

Starting SRT early would be an over-treatment for many men with favorable pathology. Not all BCR develops to clinical relapse and metastatic disease.

TA—
So is it fair to say that for men with adverse pathology, it’s important to have uPSA done at a lab whose equipment is sensitive enough to read .03 and lower? I’m G8 with EPE, my last PSA reported “undetectable” <.05.